Allen J Frances M.D.

Documentation That DSM 5 Publication Must Be Delayed

because DSM 5 is so far behind schedule

I wrote last week that DSM 5 is so far behind schedule it can't possibly produce a usable document in time for its planned publication date in May 2013. My blog stimulated two interesting responses that illustrate the stark contrast between DSM 5 fantasy and DSM 5 reality. Together they document just how far behind its schedule DSM 5 has fallen and illustrate why publication must be delayed if things are to be set right. The first email came from Suzy Chapman of http://dxrevisionwatch.wordpress.com

"Re DSM 5 delays, here is a telling statement made by Dr Darrel Regier, its Vice Chair, on March 9, 2010: 'We have just released draft criteria on a website on February 10th at dsm5.org. And we'll be having a field trial starting in July of this year. We'll then have another revision based on field trial results going into a second revision or second field trial in July of 2011. As a result, we will not have our final recommendations for the DSM-V probably until early 2011'."

"Please note the dates. Dr Regier's promised timetable has been missed by more than a year- we still don't have final recommendations."

Dayle Jones PhD is head of the task force of the American Counseling Association that monitors DSM 5. She sent in a timeline comparing DSM 5 promised deadlines with actual delivery dates:

"The DSM 5 academic/large clinic field trials were designed to have two phases. Phase 1 was first scheduled to begin in June 2009, but had to be postponed for a year because the criteria sets were not ready. The timetable for field trial completion was unrealistic from the start and not surprisingly the end dates have been repeatedly postponed from early 2010 to early 2011, and we're now already into 2012 with no end in sight. Phase 2, originally scheduled for September 2011 to February 2012, was to re-test those diagnoses that did poorly in Phase 1 and had to be revised. The phase 2 trials were quietly canceled. We still don't have results from the phase 1 field trials, but the APA leadership has warned us that we must accept reliabilities that are barely better than chance. Without the second stage, uncorrected problem diagnoses will be included in DSM 5."

"The separate clinician field trial has been an even worse disaster. Clinicians were originally scheduled to be trained by August 2010, enrolling patients no later than late November 2010, and ending by February, 2011. Training was finally completed 18 months late in December 2011, which means the earliest these trials could possibly end is June 2012- well after most DSM 5 final decisions will have been made. Furthermore, of the over 5000 clinicians who registered to participate, only 70 (1.4%) have begun enrolling patients for the field trial. My guess is that like academic/large clinic Phase 2 field trial, poor planning and disorganization will force cancellation."

"In my opinion, there is no process and not enough time left to ensure that DSM 5 will attain high enough quality to be used by counselors. Fortunately, we can always bypass it by using ICD-10-CM."

Sobering stuff. Its constant procrastination has at last caught up with DSM 5. Having fallen so far behind schedule, DSM 5 abruptly dropped the second stage of field testing- without public comment or justification or discussion of what would be the effects on quality and reliability. In fact, the second stage of the field trials was perhaps the most crucial step in the entire DSM 5 process - a last chance for sorely needed quality control to bring a lagging DSM 5 up to acceptable standards. The DSM 5 proposals that were weak performers in the first stage were supposed to be rewritten and retested in the second to ensure that they deserved to be included in the manual.

APA is now stuck with the most unpalatable of choices- protecting the quality of DSM 5 vs protecting the publishing profits to be gained by premature publication. Given all the delays, it can't possibly do both- a quality DSM 5 can't be delivered in May 2013.

All along, it was predictable (and predicted), that DSM 5 disorganization would lead to a mad, careless dash at the end. The DSM's have become far too important to be done in this slapdash way- the high cost to users and the public of this rush to print is unacceptable. Unless publication is delayed, APA will be offering us official DSM 5 criteria that are poorly written, inadequately tested, and of low reliability. The proper alternative is clear: APA should delay publication of DSM 5 until it can get the job done right. Public trust should always trump publishing profits.

I purchased DSM IV when published in 1994. Original prediction for DSM 5 release was 2012. Now 18 years after last publication, and 12 years after text revisions DSM-IV-TR in 2000, the psychiatric community doubts if 5 will be ready by 2013. There are mega problems when brilliant professionals cannot produce an acceptable update of their diagnostic manual in 18 years.
I've noticed an erosion of objectivity and inroad of subjectivity and personal prejudice in the last two decades--in Psychology Today and other mental health publications. I see articles tainted by politics, individual belief, and popular tone and interests encroaching on the fascinating analytical study of pure neuroscience. With PT the articles at present are less academic with less scholarly prose and more opinionated and pop culture. The editors may believe this is what their readers want, but it's not pure psychology. Finances may be the bottom line in the DSM 5 debacle, as in special interests donating hefty sums to research etc. as long as they oversee "their" representation in the text. Politicians have already sold out, but I'd hoped the esteemed mental health profession would never do so. Sad and disappointing if they really have, not to mention devastating to society.

This whole thing is based on the psychiatrists wanting legitimacy, the pharmaceutical companies wanting profits, and an unholy and symbiotic relationship between the two of them which is in turn parasitic towards the general public.

Psychiatry in and of itself has no legitimacy, however what psychiatrists have figured out is that if you have a bunch of colorful little pills to give to people for the 'disorders' that the psychiatrists themselves made up then this gives the psychiatrists a semblance of legitimacy, almost like a real doctor, kind of sort of maybe. The pharmaceutical companies are more than happy to exploit the psychiatrists' need for legitimacy by providing the psychiatrists with all the colorful little pills a psychiatrist could want, which in turn makes the pharmaceutical companies billions upon billions of dollars annually.

This leads to the current situation- ever increasing numbers of ill-defined and societially pervasive 'disorders' which = more opportunities for the psychiatrists to prescribe their colorful little pills which = more contrived legitimacy for the psychiatrists which = more profits for the pharmaceutical companies. The general public is just a resource to be exploited in this scenario.